385601116-12-1-2025-14-AS-BCHN-DQSTGE-20260129134302

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385601116
Report Date: 12/01/2025
Date Signed: 12/01/2025 02:50:36 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/26/2025 and conducted by Evaluator John Calandra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20250626124143

FACILITY NAME:	COTERIE CATHEDRAL HILL		FACILITY NUMBER:	385601116
ADMINISTRATOR:	MATTHEW TURNER		FACILITY TYPE:	740
ADDRESS:	1001 VAN NESS AVENUE		TELEPHONE:	(415) 915-6615
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	260	CENSUS: 214	DATE:	12/01/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Matthew Turner, General Manager		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff mismanaged resident's medications.
Staff did not respond to resident's call button in a timely manner.
Staff did not provide services to resident as stated in care plan.
Staff did not notify resident's responsible party of changes of resident's care plan.
Staff overcharged resident.

INVESTIGATION FINDINGS:

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On 12/1/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver conclusionary findings for this complaint. LPA was greeted by Matthew Turner and explained the purpose of the visit.

Complaint alleged that staff mismanaged resident’s medication. According to the Reporting Party, there would be times where medications would be found on the floor of R1’s room or it was evident that R1 was not getting their medications. Based on document review and interviews, facility staff did handle R1’s medications for them. LPA toured the physical plant as part of the investigation. Based on observations and interviews, no evidence of mismanagement of medications could be found as R1 is no longer a resident of the facility and their records are no longer stored at the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20250626124143

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: COTERIE CATHEDRAL HILL	FACILITY NUMBER: 385601116
	VISIT DATE: 12/01/2025

NARRATIVE

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Complaint also alleged that staff did not respond to resident’s call button in a timely manner. Reporting Party alleged that when R1 pushed their call button, no staff would respond. Based on interviews and record review, the facility’s policy is for caregivers to respond to call buttons within 10 minutes or less. Based on interviews, it takes staff less than 10 minutes to respond to a call button and if they are busy, other caregivers can be called on to help.

Complaint also alleged that staff did not provide services to resident as specified in their care plan. Per interview with Reporting Party, R1 was to get showers on a daily basis per their care plan and status checks throughout the day. According to the Reporting Party, status checks were not done in person. Based on interviews and record review, R1 did ask for a shower every day and was provided one by their 1:1 caregivers as R1’s private caregivers asked the facility staff not to provide care.

Complaint alleged that staff did not notify resident's responsible party of changes to R1's care plan. Based on document review and interview, the facility’s Care Coordination Director and Regional Care Director contacted R1’s responsible party and discussed each update to the care plan with the responsible party.

Complaint alleged that staff overcharged resident. According to the Reporting Party, R1’s level of care costs were raised from $2,200 to nearly $6,000. Based on document review and interview, R1’s needs changed over time and thus R1 was reassessed by the facility’s Care Coordination Director and Regional Care Director. They notified R1's responsible party of the change who agreed to the change in level of care and cost associated. In addition, based on document review and interview, level of care and monthly charges are explained in the facility's admission agreement.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore the above allegations are unsubstantiated at this time.

No deficiencies cited during today's visit.

An exit interview was conducted. This report was reviewed with facility representatives and a copy provided.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2025

LIC9099 (FAS) - (06/04)

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